Left ventricular papillary fibroelastoma: two-dimensional echocardiographic detection and surgical resection.

We report a patient with a papillary fibroelastoma arising from the left ventricular posterior wall. The tumor was detected incidentally during echocardiography undertaken to evaluate aortic stenosis. Possible complication from tumor embolization was avoided by surgical resection during aortic valve replacement.

Postinfarction atrioventricular septal rupture.

Postinfarction communication between a left ventricular aneurysm and the right atrium is a rare acquired disease. We report a case of a 72-year-old man who recently had dyspnea on minimal exertion and was found to have left ventricle-to-right atrial shunt by two-dimensional transthoracic echocardiography. This diagnosis was confirmed with transesophageal echocardiography, cardiac catheterization, and angiography. The patient underwent successful repair but died of multisystem failure. This case shows the importance of transthoracic echocardiography for the adequate diagnosis and management of such cases.

[Mid-term results of heart valve replacement with 2 types of pericardial heterograft. Apropos of 208 cases]. / Résultats à moyen terme du remplacement valvulaire à l'aide de deux types d'hétérogreffes péricardiques. A propos de 208 patients.

Medium-term results of valve replacement with a pericardial bioprosthesis were analysed in 141 patients receiving an Ionescu-Shiley aortic prosthesis and in 67 patients receiving a Mitroflow aortic (42), mitral (21) or double mitro-aortic (4) bioprostheses. There were 8 deaths in the operative (5.7%) and medium term (56 months) follow-up periods in the Ionescu group and a cumulative survival of 625 patient-years. There were 16 late deaths, 8 of cardiac origin. The 8 year survival and good functional results rates were 71% and 53% respectively. The linear rates of thrombo-embolism, endocarditis, reoperation, valvular dysfunction and regurgitation were 3.5, 1.1, 2.6, 2.7 and 6.1% patient-years. The corresponding figures in the Mitroflow bioprostheses were 0.5, 1.0, 3.1, 3.1 and 5.6% patient-years, but the average follow-up was shorter (36 months) with a cumulative survival of 195 patient-years. These results underline the frequency of primary valve dysfunction the mechanisms of which are: early tear in areas of high mechanical stress and late calcification. However, the hemodynamic profiles of this type of prosthesis are better than those of porcine bioprostheses which make them a valuable alternative in elderly patients operated for calcific aortic stenosis with a small aortic ring.

[Triple-valve replacements]. / Les triples remplacements valvulaires.

34 patients aged between 17 and 62 years underwent triple valve replacement, 14 of whom exclusively with Starr-Edwards prosthesis; 25 patients were operated at Stage III and 4 at Stage IV of the NYHA classification; the operative mortality was 14%, the late mortality 21%. The actuarial survival curve shows 66% survival at 5 years; in all, 21 good results were obtained with a follow-up ranging from 3 months to 11 years (average 41 months). A notable late complication specific to these patients was dysfunction of the tricuspid prosthesis; a gradient across the tricuspid prosthesis was observed in 14 postoperative catheter studies; one of these patients had to be reoperated for thrombosis of a Starr-Edwards tricuspid prosthesis. Analysis of the results of this series suggests that surgery is beneficial, especially when the very precarious preoperative state of these patients is taken into consideration.

[Study of the etiologic mechanism of valvular regurgitation using Doppler echography]. / Etude du mécanisme étiologique des régurgitations valvulaires en écho-Doppler.

Doppler echocardiography is currently the method of choice for diagnosing and determining the mechanism and etiology of valvular regurgitation. The recent introduction of transesophageal echo coupled with color Doppler has increased the value of these ultrasonic methods. The analysis of the valvular lesion should be particularly precise and accurate in severe mitral insufficiency because of the possibility of surgical valvuloplasty, the indications of which are now much broader than was the case at the beginning of the nineteen eighties.

[Aneurysm of the interauricular septum and operated left-right shunt. Echocardiographic aspects]. / Anévrysme du septum inter-auriculaire avec shunt gauche-droite opéré. Aspect échocardiographique.

The echocardiographic appearances of a patient with a rare congenital malformation, interatrial septal aneurysm (IASA) associated with a hemodynamically significant left-to-right shunt, are described. A 52 year old man with Noonan's syndrome was admitted to hospital for atrial flutter with right heart failure, which, on investigation, led to the diagnosis of a rare type of atrial septal defect; 2D echocardiography showed an isolated aneurysm of the interatrial septum; cardiac catheterisation demonstrated a significant left-to-right (5 volumes of oxygen per 100 ml). The patient underwent surgery which confirmed the presence of a multiperforated aneurysm of the interatrial septum in the region of the fossa ovalis. This abnormality was resected and the interatrial defect closed; there were no postoperative complications and the cardiomegaly regressed significantly. The authors underline the M mode and 2D appearances of this condition; although it may be difficult on M mode examination to distinguish an IASA from other conditions giving rise to mobile intra-right atrial echos, such as Chiari's malformation, tricuspid valve vegetations, intraatrial tumour or thrombus or Eustachian valve, 2D examination using different incidences and contrast injections generally confirms the diagnosis. Surgery is often necessary after the detection of this echocardiographic abnormality: the surgical indications are described.

[Value of transesophageal echocardiography. From a preliminary experience of 532 cases]. / Intérêt de l'échographie cardiaque par voie transoesophagienne. A partir d'une expérience préliminaire de 532 cas.

Transesophageal echocardiography (TEE) was introduced recently in France. The aim of this study was to review the diagnostic value of this technique after 8 months' use in our cardiology department. A total of 532 TEE studies were carried out between April and December 1988 in 396 patients (average age 54 years, range 17 to 89 years) at Tenon Hospital. The failure rate was 1.8 per cent (N = 10), over half of which occurred at the beginning of the operator's experience. TEE was particularly valuable compared with the standard transthoracic approach in the following instances: the investigation of mitral stenosis, especially before percutaneous valvuloplasty (N = 75). A left atrial thrombus was demonstrated in 5 cases by TEE vs none by standard echocardiography. There was also a much higher diagnostic sensitivity for small interatrial shunts (40 vs 6) resulting from transseptal catheterisation. In the preoperative investigation of severe mitral regurgitation (N = 29). The etiology was accurately diagnosed in 29 vs 26 cases, and the mechanism of the regurgitation was correctly classified especially in cases of ruptured chordae (15 vs 6 cases). In endocarditis (N = 26) by the visualisation of abscess of the aortic ring (7 vs 1) and vegetations (19 vs 8). In prosthetic valve dysfunction (N = 65) by the demonstration of primary degeneration of bioprostheses (7 vs 4), perivalvular leaks (10 vs 4) and non-occlusive thrombi of mechanical prostheses (3 vs 0). In cases of intracardiac tumours, dissection of the thoracic aorta and atrial septal defects.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echography in surgical mitral insufficiency. Pathologic diagnosis and provision of the surgical procedure]. / L'échographie des insuffisances mitrales chirurgicales. Diagnostic lésionnel et prévision du type de chirurgie.

The aim of this study was to determine the reliability of preoperative transthoracic and transesophageal echocardiography compared with the surgical findings in pure or dominant severe mitral regurgitation with respect to: the evaluation of the lesions, mechanism and etiology; the provision of the type of surgery (valve replacement or reconstruction); One hundred and fifty patients were divided into two groups: Group I (N = 120) in which preoperative assessment included transthoracic echo-Doppler coupled with color Doppler in the last 32 patients; Group II (N = 30) operated recently who underwent both transesophageal and transthoracic echo-Doppler examination. In Group I, the sensitivity of transthoracic echo in the evaluation of the etiological was 86% overall [100% in rheumatic valve disease (N = 28), 86% in degenerative or dystrophic valves (N = 72), 44% in endocarditis (N = 9), 87% in ischaemic dysfunction (N = 8)]. The echo evaluation of the mechanism of the regurgitation was also reliable with the exception of ruptured chordae in which direct visualisation of the rupture was only possible in 19 of the 64 cases (30%). The type of surgery predicted by echo was practiced in 87% of cases.

[Recurrent ejection of aortic valve prostheses. Apropos of 22 case reports]. / Les désinsertions itératives des prothèses valvulaires aortiques. A propos de 22 observations.

Twenty two cases of recurrent perivalvular leaks in aortic valve prostheses were reviewed in a multicentre cooperative study. From 1963 to 1978, 22 patients, mean age 39 years, underwent aortic valve replacement; 18 patients had aortic regurgitation, 6 due to infective endocarditis, and 4 patients had calcific aortic stenosis. Eight Starr-Edwards, 6 Smeloff-Cutter, 2 Braunwald-Cutter, 3 Björk, 1 Lillehei-Kaster and 2 bioprostheses were inserted. All 22 patients had to be reoperated for perivalvular leaks due to active or previous infective endocarditis in 7 cases. The prostheses implanted (3 reinsertions, 19 valve replacements) were 10 Starr-Edwards, 4 Smeloff-Cutter, 5 Björk, 1 Lillehei-Kaster, 1 Magovern and 1 bioprosthesis. All 22 patients had further perivalvular leaks, 6 caused by infective endocarditis, and 15 patients underwent a third operation. The prostheses implanted this time (2 reinsertions, 13 valve replacements) were 4 Starr-Edwards, 3 Smeloff-Cutter, 7 Björk and 1 bioprosthesis. Four patients had a third perivalvular leak, and 2 patients a fourth perivalvular leak. The first and second episodes of perivalvular leak were detected early in over half the cases. They were associated with cardiac failure, angina and hemolysis in 20 to 45% of cases. The average period between the first and second operations, and the 2nd and 3rd operations were 15 months and 9 months respectively. Overall, 11 patients died (50%), 4 due to cardiac failure and 3 of sudden death; 3 patients have been lost to follow-up (14%), and there are 8 survivors (36%) with a mean follow-up period of 5 years. However, the mortality rate when the cause of perivalvular leak was infective, was 82%, and only 18% when the cause was mechanical. The factors which favour recurrent perivalvular leaks are infection (30% of cases) and technical difficulties related to the poor quality of the aortic ring (calcification, dystrophy or dilatation). The prevention of this complication depends on careful peroperative technique, the use of certain surgical bypass techniques, a constant battle against infection, and regular examination of operated patients.

An unusual beta-cell adenoma.

An unusual case of insulinoma in a 51-year-old man demonstrates the difficulties in diagnosing and treating hypoglycemia. From the many laboratory tests and procedures performed, the only findings typical of insulinoma were inappropriate values of plasma immunoreactive insulin in relation to the corresponding values of blood glucose, and these were sporadic. A small beta-cell adenoma in the pancreatic head was the cause of the hypoglycemia.

[Osteogenesis imperfecta and aortic incompetence. One case with pathological findings. Review of the literature (author's transl)]. / Ostéogenèse imparfaite et insuffisance aortique. Une observation avec documents anatomiques. Revue de la littérature.

Cardiovascular manifestations of Lobstein's disease are rare, probably unrecognized, and determining factors for the final prognosis, the most frequent lesion being aortic incompetence. The eleventh case to be reported with pathological findings in the literature is described. This complication is usually found in men, blood regurgitation being large in amount, symptomatic, and progressive. Its mechanism is related less to dilatation of the aorta and its ring than to valvular changes, they being frequently bicuspid and dysplasic. Histological findings, not however pathognomonic, are myxoid degeneration in the valves and parietal cystic necrosis in the aortic wall. Apart from the absence of an aneurysm and aortic dissection, macro- and microscopic lesions are similar to those observed in Marfan's syndrome and osteogenesis imperfecta. Operative therapy was employed in all eleven cases, with three postoperative deaths and three later deaths. Certain complications arise from uncontrollable severe hemorrhage, which justifies the use of valve heterografts not requiring antivitamin K administration.